Urinary Tract Infection

Urinary tract infections (UTIs) are a leading cause of

morbidity in persons of all ages. Sexually active young
women, elderly persons and those undergoing genitourinary
instrumentation or catheterization are at risk.
I. Acute uncomplicated cystitis in young women
A. Sexually active young women are most at risk for
UTIs.
B. Approximately 90 percent of uncomplicated cystitis
episodes are caused by Escherichia coli, 10 to 20
percent are caused by coagulase-negative Staphylococcus
saprophyticus and 5 percent or less are
caused by other Enterobacteriaceae organisms or
enterococci. Up to one-third of uropathogens are
resistant to ampicillin and, but the majority are
susceptible to trimethoprim-sulfamethoxazole (85
to 95 percent) and fluoroquinolones (95 percent).
C. Patients should be evaluated for pyuria by urinalysis
(wet mount examination of spun urine) or a
dipstick test for leukocyte esterase.\

Urinary Tract Infections in Adults

Category Diagnostic
criteria
First-line
therapy
Comments
Acute uncomplicated
cystitis
Urinalysis
for pyuria
and hematuria
(culture
not required)
TMP-SMX
DS
(Bactrim,
Septra)
Trimethopri
m
(Proloprim)
Ciprofloxaci
n (Cipro)
Ofloxacin
(Floxin)
Three-day
course is best
Quinolones
may be used
in areas of
TMP-SMX
resistance or
in patients
who cannot
tolerate
TMP-SMX
Recurrent
cystitis in
young
women
Symptoms
and a urine
culture with
a bacterial
count of
more than
100 CFU
per mL of
urine
If the patient
has more
than three
cystitis episodes
per
year, treat
prophylactically
with
postcoital,
patient- directed
or
continuous
daily therapy
Repeat therapy
for seven
to 10 days
based on culture
results
and then use
prophylactic
therapy
Acute cystitis
in
young
men
Urine culture
with a
bacterial
count of
1,000 to
10,000 CFU
per mL of
urine
Same as for
acute uncomplicated
cystitis
Treat for
seven to 10
days
Acute uncomplicated
pyelonephritis
Urine culture
with a
bacterial
count of
100,000
CFU per mL
of urine
If
gram-negati
ve organism,
oral
fluoroquinol
one
If
gram-positiv
e organism,
amoxicillin
If parenteral
administration
is required,
ceftriaxone
(Rocephin)
or a
fluoroquinolone
If
Enterococcu
s species,
add oral or
IV
amoxicillin
Switch from IV
to oral administration
when
the patient is
able to take
medication by
mouth; complete
a 14-day
course
Complicated
urinary
tract
infection
Urine culture
with a
bacterial
count of
more than
10,000 CFU
per mL of
urine
If
gram-negati
ve organism,
oral
fluoroquinol
one
If
Enterococcu
s species,
ampicillin or
amoxicillin
with or without
gentamicin
(Garamycin)
Treat for 10 to
14 days
Catheter-a
ssociated
urinary
tract infection
Symptoms
and a urine
culture with
a bacterial
count of
more than
100 CFU
per mL of
urine
If
gram-negati
ve organism,
a
fluoroquinolone
If
gram-positiv
e organism,
ampicillin or
amoxicillin
plus gentamicin
Remove catheter
if possible,
and treat
for seven to
10 days
For patients
with long-term
catheters and
symptoms,
treat for five to
seven days
Antibiotic Therapy for Urinary Tract Infections
Diagnostic
group
Duration
of
therapy
Empiric options
Acute uncomplicated
urinary
tract
infections
in women
Three
days
Trimethoprim-sulfamethoxazole
(Bactrim DS), one double-
strength tablet PO twice
daily
Trimethoprim (Proloprim), 100 mg
PO twice daily
Norfloxacin (Noroxin), 400 mg
twice daily
Ciprofloxacin (Cipro), 250 mg
twice daily
Lomefloxacin (Maxaquin), 400 mg
per day
Ofloxacin (Floxin), 200 mg twice
daily
Enoxacin (Penetrex), 200 mg
twice daily
Sparfloxacin (Zagam), 400 mg as
initial dose, then 200 mg per day
Levofloxacin (Levaquin), 250 mg
per day
Nitrofurantoin (Macrodantin), 100
mg four times daily
Cefpodoxime (Vantin), 100 mg
twice daily
Cefixime (Suprax), 400 mg per
day
Amoxicillin-clavulanate(Augment
in), 500 mg twice daily
Acute uncomplicated
pyelonephr
itis
14
days
Trimethoprim-sulfamethoxazole
DS, one double-strength tablet
PO twice daily
Ciprofloxacin (Cipro), 500 mg
twice daily
Levofloxacin (Maxaquin), 250 mg
per day
Enoxacin (Penetrex), 400 mg
twice daily
Sparfloxacin (Zagam) 400 mg initial
dose, then 200 mg per day
104.50
Ofloxacin (Floxin), 400 mg twice
daily
Cefpodoxime (Vantin), 200 mg
twice daily
Cefixime (Suprax), 400 mg per
day
Up to
3 days
Trimethoprim-sulfamethoxazole
(Bactrim) 160/800 IV twice daily
Ceftriaxone (Rocephin), 1 g IV per
day
Ciprofloxacin (Cipro), 400 mg
twice daily
Ofloxacin (Floxin), 400 mg twice
daily
Levofloxacin (Penetrex), 250 mg
per day
Aztreonam (Azactam), 1 g three
times daily
Gentamicin (Garamycin), 3 mg
per kg per day in 3 divided
doses every 8 hours
Complicated
urinary
tract
infections
14
days
Fluoroquinolones PO
Up to
3 days
Ampicillin, 1 g IV every six hours,
and gentamicin, 3 mg per kg per
day
Urinary
tract infections
in
young men
Seven
days
Trimethoprim-sulfamethoxazole,
one double-strength tablet PO
twice daily
Fluoroquinolones
D. Treatment of acute uncomplicated cystitis in
young women
1. Three-day regimens appear to offer the optimal
combination of convenience, low cost and an
efficacy comparable to that of seven-day or
longer regimens.
2. Trimethoprim-sulfamethoxazole is the most
cost-effective treatment. Three-day regimens of
ciprofloxacin (Cipro), 250 mg twice daily, and
ofloxacin (Floxin), 200 mg twice daily, produce
better cure rates with less toxicity.
3. Quinolones that are useful in treating complicated
and uncomplicated cystitis include
ciprofloxacin, norfloxacin, ofloxacin, enoxacin
(Penetrex), lomefloxacin (Maxaquin),
sparfloxacin (Zagam) and levofloxacin
(Levaquin).
4. Trimethoprim-sulfamethoxazole remains the
antibiotic of choice in the treatment of uncomplicated
UTIs in young women. Fluoroquinolones
are recommended for patients who cannot
tolerate sulfonamides or trimethoprim or who
have a high frequency of antibiotic resistance.
Three days is the optimal duration of treatment
for uncomplicated cystitis. A seven-day course
should be considered in pregnant women,
diabetic women and women who have had
symptoms for more than one week.
II. Recurrent cystitis in young women
A. Up to 20 percent of young women with acute
cystitis develop recurrent UTIs. The causative
organism should be identified by urine culture.
B. Women who have more than three UTI recurrences
within one year can be managed using one
of three preventive strategies.
1. Acute self-treatment with a three-day course of
standard therapy.
2. Postcoital prophylaxis with one-half of a
trimethoprim-sulfamethoxazole double-strength
tablet (40/200 mg).
3. Continuous daily prophylaxis for six months with
trimethoprim-sulfamethoxazole, one-half tablet
per day (40/200 mg); nitrofurantoin, 50 to 100
mg per day; norfloxacin (Noroxin), 200 mg per
day; cephalexin (Keflex), 250 mg per day; or
trimethoprim (Proloprim), 100 mg per day.
III. Complicated UTI
A. A complicated UTI is one that occurs because of
enlargement of the prostate gland, blockages, or
the presence of resistant bacteria.
B. Accurate urine culture and susceptibility are necessary.
Treatment consists of an oral
fluoroquinolone. In patients who require hospitalization,
parenteral administration of ceftazidime
(Fortaz) or cefoperazone (Cefobid), cefepime
(Maxipime), aztreonam (Azactam), imipenem-cilastatin
(Primaxin) or the combination of an
antipseudomonal penicillin (ticarcillin [Ticar],
mezlocillin [Mezlin], piperacillin [Pipracil]) with an
aminoglycoside.
C. Enterococci are frequently encountered
uropathogens in complicated UTIs. In areas in
which vancomycin-resistant Enterococcus faecium
is prevalent, quinupristin-dalfopristin (Synercid)
may be useful.
D. Patients with complicated UTIs require at least a
10- to 14-day course of therapy. Follow-up urine
cultures should be performed within 10 to 14 days
after treatment.
IV.Uncomplicated pyelonephritis
A. Women with acute uncomplicated pyelonephritis
may present with a mild cystitis-like illness and
flank pain; fever, chills, nausea, vomiting,
leukocytosis and abdominal pain; or a serious
gram-negative bacteremia. Uncomplicated
pyelonephritis is usually caused by E. coli.
B. The diagnosis should be confirmed by urinalysis
and by urine culture. Urine cultures demonstrate
more than 100,000 CFU per mL of urine in 80
percent of women with pyelonephritis. Blood
cultures are positive in up to 20 percent of women
who have this infection.
C. Empiric therapy using an oral fluoroquinolone is
recommended in women with mild to moderate
symptoms. Patients who are too ill to take oral
antibiotics should initially be treated with a
parenterally third-generation cephalosporin,
aztreonam, a broad-spectrum penicillin, a
quinolone or an aminoglycoside.
D. The total duration of therapy is usually 14 days.
Patients with persistent symptoms after three days
of antimicrobial therapy should be evaluated by
renal ultrasonography for evidence of urinary
obstruction or abscess.